Chest pain that sounds like indigestion, feels mild or seems “atypical” can still be myocardial infarction. The difficult question is not whether troponin is useful, but which patients actually need testing — and how much weight we should give symptoms, cardiovascular risk factors and clinical judgement.

Professor Rick Body looks at the evidence behind those decisions, drawing on his own research and other studies of patients with suspected acute coronary syndromes. He explores which clinical features genuinely change the probability of myocardial infarction, which are less useful than we might think, and how to balance the risks of missing MI against unnecessary investigation.

In this podcast:

• Why “heavy” or “crushing” chest pain only modestly increased the probability of myocardial infarction in Rick’s study population.

• Why indigestion-like pain should not automatically reassure us, and why apparently “atypical” symptoms cannot safely exclude acute coronary syndrome.

• The diagnostic significance of associated features such as vomiting and, particularly, sweating observed by the clinician.

• Why dividing chest pain into “typical” and “atypical” presentations has limited discriminatory value.

• Why having no recognised hypertension, hyperlipidaemia, diabetes, smoking history or family history does not rule out acute myocardial infarction.

• How clinician gestalt does track with risk, but is not sufficiently reliable on its own to rule myocardial infarction in or out.

• Why none of this means testing everyone: Rick’s practical approach is to seek a convincing alternative explanation and use troponin when MI remains a plausible diagnosis that has not otherwise been adequately explained.

The numerical probabilities discussed come from populations already selected for investigation of suspected myocardial infarction, so they should not simply be transferred to every patient presenting with chest pain.

About Rick Body

Rick Body is Professor of Emergency Medicine at the University of Manchester and an Honorary Consultant in Emergency Medicine at Manchester University NHS Foundation Trust. His research has focused extensively on diagnostics in acute coronary syndromes, including cardiac troponin and strategies for the early rule-out of myocardial infarction.

Timestamps

00:00 – Which patients with chest pain need a troponin? 02:00 – What individual symptoms do to pre-test probability 05:00 – Vomiting and observed sweating 08:00 – The problem with “typical” and “atypical” symptoms 10:00 – Do traditional cardiovascular risk factors help? 13:00 – How reliable is clinical judgement or gestalt? 16:00 – Avoiding both under-investigation and over-investigation 17:00 – Rick’s practical approach to deciding when to test

Links and resources

The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes

Examining the signs and symptoms experienced by individuals with suspected acute coronary syndrome in the Asia-Pacific region

‘Chest pain typicality’ in suspected acute coronary syndromes and the impact of clinical experience

Do risk factors for chronic coronary heart disease help diagnose acute myocardial infarction in the Emergency Department?

Can Emergency Physician Gestalt “Rule In” or “Rule Out” Acute Coronary Syndrome? Multicentre validation study

More from St Emlyn’s

St Emlyn’s provides free, evidence-based education for the emergency and acute care community. Explore our blogs, podcasts and other resources.

If you have an idea you would like to share, would like to write with us, or want to get involved with St Emlyn’s, we’d love to hear from you.

Learning from podcasts?

If podcasts form part of your CPD, MedPod Learn helps you turn listening into documented learning. You can use it across all your podcasts — not just St Emlyn’s — to record your listening, make notes, answer questions, reflect on what you have learned and create a record of your CPD.

Recorded at Trauma 2030 at the Royal College of Surgeons in London in December 2025, this short St Emlyn’s podcast looks at one of the most challenging situations in prehospital and emergency care: traumatic cardiac arrest.

Iain is joined by Laura Kocierz, a Consultant with London’s Air Ambulance and a Consultant in Critical Care Medicine and Anaesthesia in the Midlands.

In this conversation, Laura and Iain explore how data can help us make better decisions about resuscitative thoracotomy.

Traumatic cardiac arrest is not always a simple binary event. Patients may deteriorate through a profound low-output state before complete circulatory arrest, and recognising the underlying cause quickly is critical.

Laura discusses how the surface location of a penetrating injury can help distinguish cardiac tamponade from exsanguination. A wound within the cardiac box or epigastrium carries a substantially higher likelihood of tamponade, making immediate thoracotomy an important consideration when an organised cardiac rhythm remains.

The conversation also explores the ECG as a potential surrogate for time since traumatic cardiac arrest. Sinus rhythm, bradycardia, agonal complexes and asystole may represent progressive physiological deterioration and can add useful information when the reported timing of arrest is uncertain.

This leads to an important challenge to the traditional “15-minute rule”. If the history suggests a prolonged arrest but the patient has a penetrating injury consistent with tamponade and still has an organised rhythm, Laura explains why the physiological evidence may be more useful than an uncertain reported time.

The other key message is equally important: resuscitative thoracotomy is not a treatment for exsanguination. When major blood loss is the likely cause, priorities remain haemorrhage control, blood transfusion and rapid access to definitive care, while continuing to look actively for co-existing tamponade.

In this podcast:

• Defining traumatic cardiac arrest as a clinical and physiological state
• Using wound location to estimate the likelihood of cardiac tamponade
• The significance of penetrating injury within the cardiac box and epigastrium
• Using ECG rhythm as a clue to the duration of circulatory arrest
• Why reported arrest times may be unreliable
• Rethinking the traditional 15-minute threshold for resuscitative thoracotomy
• Distinguishing tamponade from exsanguination
• Why thoracotomy should not distract from haemorrhage control and blood transfusion
• How data from London’s Air Ambulance is helping make traumatic cardiac arrest care more targeted

A short conversation with some important practical challenges to the way we think about traumatic cardiac arrest, particularly when deciding who may genuinely benefit from resuscitative thoracotomy.

Learning from podcasts?

If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection. The app is free to download, includes a one-month free trial, and offers globally adjusted pricing.

Trauma 2030

TRAUMA 2030 united experts and innovators to shape the future of trauma care. Over two days, it explored breakthroughs in science, systems, and frontline practice, fostering collaboration across disciplines. The symposium aimed to inspire research, inform policy, and build a bold roadmap for trauma care worldwide.

When does a raised troponin become a myocardial infarction? What has happened to “type 2 MI”? And how certain can we be about the diagnosis without imaging?

Iain Beardsell introduces Professor Rick Body for a practical guide to the Fifth Universal Definition of Myocardial Infarction. Rick explains the changes in terminology, troponin interpretation and diagnostic criteria, focusing on what they mean for clinicians assessing patients in the emergency department.

• Primary, secondary and procedure-related MI. The new classification replaces the previous numbered types. Rick explains why primary MI now includes coronary dissection, vasospasm and embolism, alongside atherothrombosis. He also describes how the 30-day window after coronary intervention or bypass surgery defines procedure-related MI.
• Sex-specific troponin thresholds. The definition explicitly recommends sex-specific upper reference limits. Rick discusses why this matters and encourages clinicians to understand the thresholds used by their own laboratory, rather than assuming every troponin assay works in the same way.
• A likely diagnosis versus a confirmed diagnosis. Cardiac and coronary imaging take a more prominent role in confirming MI and identifying its cause. This is particularly relevant when considering secondary MI in patients with sepsis, tachyarrhythmia or gastrointestinal haemorrhage. A troponin rise alone does not establish myocardial infarction.
• Acute and chronic myocardial injury. Rick explores the causes of myocardial injury beyond infarction, including inflammation, haemodynamic stress, catecholamine effects, toxicity and trauma. He also challenges the habit of diagnosing chronic myocardial injury from two similar troponin results during an acute ED attendance, without establishing the patient’s stable baseline or investigating the underlying cause.
• Making sense of the troponin delta. Absolute changes, percentage changes, the starting concentration, time from symptom onset and the interval between samples all influence interpretation. Rick explains why there is no single delta that works for every patient, and why sampling intervals must match the evidence supporting the thresholds being used.
• STEMI, NSTEMI and occlusive MI. The traditional terminology remains, but the definition recognises important ECG patterns beyond conventional ST elevation. Rick discusses the place of posterior MI, de Winter T waves, Wellens syndrome, the Aslanger pattern and Sgarbossa criteria within this evolving approach.

The episode also considers the practical consequences of these changes. More investigation brings additional resource demands, and Rick highlights the uncertainty about whether a more extensive assessment of chronic myocardial injury will improve patient outcomes.

Professor Nick Mills, first author of the new definition, adds an important clarification: a working clinical diagnosis can guide initial treatment. Imaging helps identify the cause and improve diagnostic certainty, but unavailable or inappropriate angiography does not prevent a clinical diagnosis. In secondary MI, managing the presenting illness remains the immediate priority.

Rick also notes that HEART, T-MACS, EDACS and MI-3 are not addressed in the document. He interprets this as being outside its scope, rather than a change to their use.

The post includes Rick’s video presentation and details of ADOPT-UDMI, an education, evaluation and research programme inviting clinicians from all specialties to help put the new classification into practice.

Read the full post: The Fifth Universal Definition of Myocardial Infarction: What Emergency Clinicians Need to Know

If podcasts form part of your CPD, MedPod Learn brings together St Emlyn’s and other medical podcasts. Browsing and listening are free. Premium adds listening-time tracking, MCQs, structured reflection prompts and an exportable learning record for CPD and appraisal, with globally adjusted pricing.

In this month’s St Emlyn’s podcast, Iain Beardsell and Simon Carley work through some of the most interesting recent posts and papers from the blog.

The conversation ranges from the latest pulmonary embolism guidance to the persistent problem of emergency department crowding, and from pre-hospital whole blood to the uneven availability of enhanced critical care across the UK.

They also look at whether TOE might help us deliver more effective CPR, why arterial pressure may be a more useful resuscitation target than simply watching compressions, and a remarkable report from Gaza that challenges some long-held assumptions about pericardiocentesis in traumatic tamponade.

As ever, the focus is less on simply repeating what the papers say and more on what they mean in practice. Some of the evidence is reassuring, some of it is uncomfortable, and several of the studies raise as many questions as they answer.

It is a discussion about uncertainty, physiology, systems and the importance of being willing to change your mind when the evidence does not fit what feels intuitively right.

Learning from podcasts?

If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection. The app is free to download, includes a one-month free trial, and offers globally adjusted pricing.

What does it really mean to become an expert in resuscitation and critical care?

It is tempting to think that expertise comes from accumulating enough facts, passing enough exams or simply spending 10,000 hours at work. In this episode, Iain Beardsell is joined by emergency physician, intensivist and medical educator Sara Crager to explore why expertise is less about how much we know and more about how we think.

Sara explains how experts develop high-quality mental models that allow them to organise information, recognise patterns and approach difficult clinical problems. Crucially, these mental models do not have to remain hidden inside the heads of experienced clinicians: they can be identified, explained and deliberately taught.

The conversation moves from the limitations of mnemonics and assessment-driven education to the value of deliberate practice, feedback and safe failure. Sara describes how an expert might organise the differential diagnosis of cardiac arrest into respiratory, haemodynamic and metabolic problems, rather than relying solely on a memorised list of Hs and Ts.

Iain and Sara then discuss Rapid Sequence, the gamified clinical-learning platform Sara created with emergency physician Ryan Ernst. Learners work through realistic cases in a simulated clinical environment, managing several patients while dealing with interruptions, competing priorities and the consequences of their decisions.

After each block, Sara and Ryan deconstruct the cases, make their clinical reasoning explicit and introduce mental models that learners can immediately apply when they try again. It is a cycle of practice, failure, teaching and repetition—without putting a real patient at risk.

They also explore why attention, storytelling and visual design matter in medical education; how “multitasking” may be better understood as rapid task switching; and what Sara has learned from turning an educational passion project into a working product.

• Why expertise is about cognitive strategies and mental models—not simply knowledge
• Why experts are made rather than born
• The limitations of the “10,000-hour rule”
• How deliberate practice differs from repetition
• When learners are ready to be taught expert ways of thinking
• Foundational knowledge versus clinically useful organisation
• Moving beyond mnemonics such as the Hs and Ts
• How experts can make their implicit reasoning explicit
• Why acquiring a new mental model can produce a sudden leap in performance
• The importance of inspiration—and giving learners an achievable pathway
• How Rapid Sequence creates a safe place to make mistakes
• Managing several patients, interruptions and cognitive load
• Teaching shock, respiratory failure and acid–base physiology
• Why engaging design is part of the educational method
• The role of games alongside podcasts, lectures and clinical experience
• Reframing multitasking as rapid task switching
• The “pause and bookmark” technique for managing interruptions
• The realities of building an independent medical-education project
• Why partnership, persistence and a genuine belief in the project matter

Learning from podcasts?

If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection. The app is free to download, includes a one-month free trial, and offers globally adjusted pricing.

In this episode of the St Emlyn’s Podcast, Iain Beardsell and Simon Carley catch up on the February blog posts, recorded in the rather unseasonal context of a UK heatwave. They begin with congratulations to Simon on his reappointment as Dean of the Royal College of Emergency Medicine, before reflecting on recent conferences including IFEM in Hamburg and Don’t Forget The Bubbles in Glasgow.

The clinical focus this month is trauma team leadership, with practical tips on interpreting trauma CT reports, maintaining momentum after the scan, performing safer log rolls, and making feedback more useful for learners and colleagues.

• Look at trauma CT images yourself as part of your own clinical learning and to integrate the scan with your examination findings.
• Treat the first CT report as a primary survey, not necessarily a definitive final report.
• Speak to the radiologist and share clinical concerns or uncertainties.
• Do not lose momentum after CT; this is a vulnerable phase in trauma care.
• Log rolls should have a purpose and should minimise movement, pain and physiological risk.
• Use clearer team communication: “Is anybody not ready to move?” and “ready, steady, move.”
• Feedback sticks when it is specific. Add “because” to positive feedback so the learner knows exactly what to repeat.
• Leadership and followership skills apply everywhere, not just in formal trauma team leader roles.

Learning from podcasts?

If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection. The app is free to download, includes a one-month free trial, and offers globally adjusted pricing.

In this episode of the St Emlyn’s Podcast, Iain Beardsell speaks with Anna Dobbie, consultant in emergency medicine and pre-hospital care, and Clinical Lead for London HEMS.

Recorded at Trauma 2030 at the Royal College of Surgeons in London, the conversation explores what it means to lead exceptional teams in one of the most high-pressure areas of emergency medicine. Anna reflects on six years as Clinical Lead for London HEMS, sharing lessons on leadership, culture, psychological safety, difficult conversations, managing strong personalities, and supporting clinicians to do their best work.

The discussion also touches on the unique nature of pre-hospital care, where teams move rapidly between downtime and high-intensity clinical decision-making, and where trust, openness and mutual respect are essential. Anna describes the importance of making sure all voices are heard, not just the loudest, and explains why leaders need to be consistent, approachable and willing to have honest conversations when things do not go as well as they should.

Anna also reflects on learning leadership on the job, the value of formal leadership training, the challenge of maintaining boundaries when you care deeply about a service, and the relationship between London’s Air Ambulance and its supporting charity.

Finally, Iain and Anna look ahead to the future of trauma care and pre-hospital medicine, including research, ECMO, marginal gains, quality improvement, and the continuing ambition to reduce preventable deaths from trauma.

Learning from podcasts?

If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection. The app is free to download, includes a one-month free trial, and offers globally adjusted pricing.

Trauma 2030

TRAUMA 2030 united experts and innovators to shape the future of trauma care. Over two days, it explored breakthroughs in science, systems, and frontline practice, fostering collaboration across disciplines. The symposium aimed to inspire research, inform policy, and build a bold roadmap for trauma care worldwide.